Published 7:53 pm, Tuesday, July 9, 2013

When my patient Mike came in for a routine medical exam, he mentioned offhandedly that he frequently has a burning pain in his chest under the sternum.

"It's not serious," he said, "because I've experienced this for 10 years."

On the contrary, I told him, his symptoms could be serious.

It's quite possible that Mike has a common illness called gastroesophageal reflux disease, or GERD. More than 60 million Americans experience heartburn, a prominent symptom of GERD. While serious, by itself it is not life threatening.

However, Mike's discomfort may be symptomatic of a far more ominous disease. He had just turned 45 and had gained more than 15 pounds. That told me I needed to investigate the possibility of heart disease, which becomes more common when people reach middle age. Once tests showed that heart disease was not present, I concluded that GERD was likely.

GERD may be the cause of pain that follows a meal or comes when one lies or bends down. Pain that seems associated with exercise, however, may point to coronary artery disease. If there is any question about the cause of pain, a cardiac evaluation should be performed.

It also worried me that Mike had experienced his symptoms for so long. Patients who have reflux for more than 10 years have an increased incidence of developing Barrett's esophagus. This condition increases the risk of esophageal cancer.

In Mike's case, I ordered an upper endoscopy test to monitor damage to his lower esophagus. The inflammation can be visually identified through an endoscope or can be evident after a biopsy sampling of the esophageal lining. A biopsy can also identify abnormalities that, in 10 percent of patients, can be a precursor to cancer of the esophagus.

Our tests showed that Mike was experiencing GERD, which can encompass a broad range of causes from intermittent reflux of gastric contents into the lower esophagus after a large, fatty or spicy meal to reflux of gastric contents into the back of the patient's throat after lying down or bending over.

Classic heartburn symptoms include a burning pain under the sternum that migrates from the lower chest up toward the neck. Less classic symptoms of GERD include a sore throat due to the regurgitation of burning stomach or intestinal fluid into the back of the throat. Patients may notice a weakening of their voice from the damage of the reflux. In addition, reflux can cause a spasm in the airway, which can induce asthma.

Most often reflux is acidic, but in some patients alkaline bile can cause symptoms. In a minority of patients, altered sensory nerves express symptoms of heartburn even though no reflux is present. The cause of this hypersensitivity of esophageal nerves is unclear, but may be due to previous damage to the esophagus from reflux.

Treatment, aimed at reducing the amount of gastric contents entering the esophagus, could involve lifestyle changes, medication and surgery. Lifestyle changes include weight loss and alteration of diet or mealtimes. Patients also do better when they sleep with the head of the bed raised two inches.

If the patient does not respond to lifestyle modification, medications can reduce acid content of the stomach or block the effect of reflux, thus relieving symptoms. Surgery, called fundoplication, strengthens the valve between the esophagus and the stomach, reducing episodes of reflux.

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Fortunately, Mike didn't need any of these treatments. By losing weight, modifying his diet and avoiding meals within two hours of bedtime, he significantly reduced the gastroesophageal reflux that had caused him a decade of pain.

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